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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004502
Report Date: 01/13/2025
Date Signed: 01/13/2025 02:26:56 PM

Document Has Been Signed on 01/13/2025 02:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:XIAO, YANGFACILITY NUMBER:
414004502
ADMINISTRATOR/
DIRECTOR:		XIAO, YANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-8111
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
01/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Yang Xiao (Coco)TIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On January 13th, 2025, at approximately 1:30 PM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, plan of correction (POC) visit. LPA met with licensee, Yang Xiao (Coco), and explained the purpose of the visit. Present during today's visit included licensee,two assistants, and 14 enrolled children (14 preschoolers). All adults living or working in the home have fingerprint clearance.

On December 13th, 2024, at approximately 9:30 AM, LPA Gil conducted an unannounced, annual inspection. During annual inspection, licensee was issued one Type B citation for having accessible cleaning supplies. Licensee was also issued two TVs for missing staff immunization for one staff and not documenting fire drills. A POC was discussed with licensee's assistant.

As of this date, LPA observed no accessible cleaning supplies in bathroom tub and kitchen area. All cleaning supplies are kept under kitchen sink with a child lock. During visit, LPA also observed Notice of Site Visit to be properly posted and available for review. Per licensee, she is has began to document fire drills.

Deficiencies cited on December 13th, 2024, have been cleared during today's visit. LPA provided licensee with a POC letter. No deficiencies were cited today.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with licensee, Yang Xiao (Coco).
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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